Monday, June 25, 2007

Clipboards or Care?

It seems health care is going from bad to worse.

Now we have "lean manufacturing" from the manufacturing industry on which to improve healthcare:
Michael Roberto, an associate professor of management at Bryant University, says the trend will continue as hospitals face increasing pressure to control costs while improving patients' safety and satisfaction.

Much of the demand for factory veterans stems from hospitals' embrace of lean manufacturing techniques. Pioneered by Toyota Motor Corp., lean manufacturing aims to cut waste and reduce defects by speeding up the production cycle, shrinking inventories and implementing just-in-time supply delivery. On hospital wards, lean tactics are used to reduce patient waiting times or prepare operating rooms faster. ThedaCare was among the first to adopt these techniques in 2002.

Ted Stiles, whose recruiting firm specializes in placing managers with backgrounds in lean manufacturing techniques, says demand among health-care providers is up tenfold this year from last year.
Once again, "health-care providers" is a term confused with doctors. Sorry, this doctor does not agree.

"Lean manufacturing" seems to me to be nothing but a euphemism for "lean staffing." Do more with less. Once again, it appears that hospital administrators would rather turn to non-medical auto-industry "efficiency" and "safety" experts, rather than asking health care professionals to recommend the best way to improve care. Instead, they turn to these "experts" to squeeze any amount of remaining professionalism from their medical staff in order to squeeze every health care dime out of the staff they have.

Why? Because nurses and doctors are "expensive" to hospitals.

But what, exactly, is the cost of these hired-gun administrators? Do we really need yet another company or administrator to tell us how to do our job? Is it all about safety and efficacy? Or might providing a better nurse-to-patient ratio be far better at improving care?

And regarding "patient satisfaction?" Ask any patient - is sitting in a dirty bed after soiling yourself and not being able to get a nurse to help you in a time of need what patients want because they've cut back on nursing staff to become more "efficient" and "safe" or "satisfying." Will these clib-board carrying types be on call at 3AM to help answer a call button?

Certainly it is important to provide a safe environment for our patients. No doctor or nurse would argue that fact. But using "safety" and "efficacy" and "patient satisfaction" as a ruse to provide less frontline care in the name of "improving efficiency" is not only potentially dangerous, but expensive too.


Addendum: NHS Blog Doctor adds his not-so-subtle pithy bit about this trend as well.


TBTAM said...

helathcare is being run by folks who know nothing about health care. It's frightening.

My mom is currently in the hospital, and in less than 24 hours I can cite you 5 serious errors in her health care.My family and I have taken to doing round the clock shifts with her to be sure she gets the care she needs.

So lean care means replacing paid trained hospital staff with family members. How families without docs or nurses in them do it, I don't know.,

DrWes said...


Your experience echos a similar one I had with my father's recent hospitalization. It helped that I was a staff physician who knew which strings to pull and to whom to complain if a problem occurred. Gratefully, I got responses. But for the average person without a loved one to act as a patient advocate, the potential for problems in today's reduced-nurse wards is increased.

After reading your comment, I was left to wonder... what should we physicians do about this? The over-regulated health care system focused on "safety" seems to be missing the bigger picture. There is probably no simple answer to this conundrum. Is "moving meat" through the system with better efficiencies going to help with the physical and psychological challenges of the hospitalized patient? Nurses may hold the keys to this issue: why the errors? Why the difficulty responding to call lites? Is there a language barrier? Understaffing? Is anyone asking them? Or is an auto-industry yahoo going to be a better one to answer these questions?

What is certain, the drive to make cost-saving cuts of not only personnel, but the quality of personnel (i.e., hiring MA's rather than RN's or LPN's) will result in a continued erosion of care in our nation's hospitals.

Certainly, the solution is not a simple one either: hospitals can't find enough nurses these days. So for now, we're left helping our loved ones ourselves. But then again, perhaps we could use these administator's salaries to hire a few more front-line personnel (quality nurses or social workers) with competitive salaries...

Anonymous said...

Dr. Wes,

I think you don't completely understand the toyota system. Docs are actually making more money this way, and are happier. No one is trying to tell Drs how to do their job. Its about eliminating waste, like making a Dr. have to call the pharmacy 3 times to get meds for a patient.
Check out this article
Check out this article

DrWes said...

Anony 5:23 -
From your article:

"For their part, nurses can focus on coordinating and managing the patient's care - not just on following a doctor's orders. Tasks once done by registered nurses now are done by licensed practical nurses or certified nurse assistants. The goal is to make better use of the skills of each. (And I would add, save costs by hiring less skilled workers, not that this is always a bad thing - but what happens when the knowledge (doctors) are not there on the nigth shift?)

Nurses are not expected to be doctors. But they are expected to understand what the doctor is trying to do and his or her plan in caring for the patient. It means they can ask the right questions if something is not working."

In essence, this is a collaborative team approach described in the article. I agree, this should be the norm. First, doctors cannot assemble "teams" each time they make rounds; to do so would slow rounds to a crawl in most hospitals. The article suggests the real cost savings of this approach seems to be due to shortened length-of-stays. Certainly if pt outcomes are not affected, this is a good thing. But when we cut back on the skill level or number of the help (nurses) employed (because of perceived greater "efficiencies"), it's just a matter of time before accidents will happen.